Chapter 70: Seizures/Epilepsy Flashcards
(146 cards)
1
Q
Define epilepsy.
A
A chronic seizure disorder characterized by various types of seizures.
Epilepsy has multiple drug treatments available.
2
Q
What are some symptoms of seizures?
A
- Uncontrolled jerking movements (e.g., tonic-clonic seizures)
- Momentary loss of awareness (e.g., absence seizures)
Symptoms can vary widely among individuals.
3
Q
What is the most common test used to diagnose epilepsy?
A
Electroencephalogram (EEG)
An EEG records electrical activity in the brain and can show abnormal patterns even when the patient is not having a seizure.
4
Q
Which drugs can cause seizures at high doses and in renal impairment?
A
- Opioids
- Carbapenems
- Cephalosporines
- Penicillins
- Lithium
- TCA
- Baclofen
- Diphenhydramine
- Metronidazole
- Stimulants
5
Q
What psychiatric medication is known to increase seizure risk?
A
- Bupropion
- clozapine
- tricyclic antidepressants
- Lithium
6
Q
List classes of anti-infectives that can cause seizures.
A
- Quinolones
- Carbapenems
- Cephalosporins
- Penicillins
7
Q
What are the three main types of seizures?
A
Focal seizures, generalized seizures, unknown onset seizures
Seizures are classified based on where they start in the brain.
8
Q
Where do focal seizures start?
A
One side of the brain
Focal seizures can spread to the other side.
9
Q
Where do generalized seizures start?
A
Both sides of the brain
Generalized seizures affect the entire brain from the onset.
10
Q
What is a focal aware seizure?
A
A seizure where the patient experiences no loss of consciousness
Previously known as a simple partial seizure.
11
Q
What is a focal seizure with impaired awareness?
A
A seizure where the patient experiences loss of consciousness
Previously known as a complex partial seizure.
12
Q
What are the motor symptoms of seizures?
A
- Sustained rhythmical jerking movements (clonic)
- Limp or weak muscles (atonic)
- Muscle twitching (myoclonus)
- Rigid or tense muscles (tonic)
Motor symptoms provide insight into the type of seizure occurring.
13
Q
What is known as absent seizures?
A
Generalized seizures with non-motor symptoms which typically present as staring spells
14
Q
What is Status Epilepticus (SE)?
A
A seizure that lasts five minutes or more
SE is a medical emergency that can lead to brain damage.
15
Q
What is the initial treatment for Status Epilepticus?
A
A benzodiazepine injection
This is crucial for stabilizing the patient’s condition.
16
Q
What should be done if IV access is difficult during a seizure?
A
Midazolam can be given intramuscularly (IM)
This alternative route is important for effective treatment.
17
Q
What are non-injectable options for SE treatment if urgent medical care is not available?
A
- Diazepam rectal gel (Diastat AcuDial)
- Intranasal midazolam
- Buccal midazolam
These options allow for treatment outside of a medical facility.
18
Q
What is the focus during the 0-5 minutes of SE management?
A
- Stabilize circulation, airway, and breathing
- Time the seizure
- Start ECG
- Check ASM levels and electrolytes
- Treat low blood glucose with dextrose
This phase is critical for ensuring the patient’s immediate safety.
19
Q
What should be done during the 5-20 minutes of SE management if seizures continue?
A
- Give IV lorazepam
- Give IM midazolam
- Give IV diazepam
- Alternatives: rectal diazepam, intranasal or buccal midazolam
Quick intervention is necessary to prevent further complications.
20
Q
What is the second treatment phase (20-40 minutes) for SE?
A
- Give non-benzodiazepine ASM:
- IV fosphenytoin
- Valproic acid
- Levetiracetam
- Alternative: IV phenobarbital
This phase focuses on stronger medications to control ongoing seizures.
21
Q
What is the third treatment phase for refractory SE?
A
No clear evidence to guide therapy; repeat second-line therapy or use midazolam, pentobarbital, or propofol
This phase is for cases that do not respond to initial treatments.
22
Q
What is Diastat AcuDial prescribed for?
A
Patients who are at risk of long-lasting seizures
It includes special dispensing and counseling requirements for pharmacists.
23
Q
What does each package of Diastat AcuDial contain?
A
Two rectal syringes prefilled with diazepam rectal gel
24
Q
What should not be done abruptly with ASMs?
A
They should not be stopped abruptly
25
What are adjuvant treatment options for chronic seizure management?
* Medical marijuana (cannabis)
* Ketogenic diet
* Vagal nerve stimulation
* Surgical intervention
26
What is Epidiolex?
The first cannabis-derived medication approved by the FDA to treat rare forms of epilepsy
27
Does Epidiolex contain tetrahydrocannabinol (THC)?
No
28
What is a ketogenic diet used for?
Patients with refractory seizures (not responding to medications)
29
What is the typical ratio of fats to combined protein and carbohydrates in a ketogenic diet?
4:1
30
What is ketosis?
An elevated ketone state that can lead to a reduction in seizure frequency
31
What are broad-spectrum ASMs used for?
Medications that treat both focal and generalized seizures, such as lamotrigine, levetiracetam, topiramate, and valproic acid
## Footnote
Broad-spectrum ASMs are effective for a wider range of seizure types compared to narrow-spectrum ASMs.
32
Which ASM is specifically used for absence seizures?
Ethosuximide
## Footnote
Ethosuximide is tailored for treating absence seizures, a specific type of seizure.
33
What are common CNS effects of ASMs?
* Dizziness
* Confusion
* Sedation
* Ataxia/coordination difficulties
## Footnote
These effects increase the risk of cognitive impairment and falls.
34
What is the mechanism of action for benzodiazepines and phenobarbital?
Enhances GABA effect
## Footnote
Benzodiazepines work by increasing the inhibitory effect of GABA in the brain.
35
What is the MOA of valproate?
They block sodium channels and increase GABA
## Footnote
This mechanism helps in reducing neuronal excitability.
36
What is the MOA of Carbamazepine, phenytoin, and topiramate?
Blocks sodium channels
37
What condition is associated with all ASMs regarding mood?
Warning for suicide risk and monitoring for changes in mood or behavior
## Footnote
This is especially important for patients with psychiatric conditions.
38
What is a significant risk associated with ASMs concerning bone health?
Bone loss and increased fracture risk
## Footnote
Supplementation with calcium and vitamin D is recommended for all patients on ASMs.
39
Which serious skin conditions can ASMs cause?
* Stevens-Johnson syndrome (SJS)
* Toxic epidermal necrolysis (TEN)
## Footnote
Higher ASM blood levels increase the risk of these conditions.
40
What should patients on ASMs be supplemented with?
* Calcium and vitamin D
* Folate for women of childbearing age
* Possibly carnitine for those on valproic acid
* Biotin, selenium, and zinc if alopecia develops on lamotrigine and valproic acid
## Footnote
These supplements help mitigate the side effects of ASMs.
41
What neurotransmitter deficiency can lead to seizures?
Gamma-aminobutyric acid (GABA)
## Footnote
GABA is an inhibitory neurotransmitter; its deficiency can trigger seizure activity.
42
What neurotransmitter excess can lead to seizures?
Glutamate
43
What is Lamotrigine brand name?
Lamictal, Lamictal ODT, Lamictal Starter Kit, Lamictal XR, Subvenite, Subvenite Starter Kit-Blue, Green, Orange
## Footnote
Lamotrigine is also used for bipolar disorder.
44
What is the initial dosing schedule for Lamotrigine during Weeks 1 and 2?
25 mg daily
## Footnote
Dosing can vary based on interacting drugs.
45
What is a boxed warning associated with Lamotrigine?
Serious skin reactions, including SJS/TEN
## Footnote
The rate of rash is greater in pediatrics than adults.
46
What warnings are associated with Lamotrigine?
**Multiorgan hypersensitivity reactions (DRESS)**, aseptic meningitis, blood dyscrasias, cardiac rhythm abnormalities, hemophagocytic lymphohistiocytosis (HLH)
## Footnote
These reactions can be fatal.
47
List some common side effects of Lamotrigine.
* **Alopecia**
* N/V
* Somnolence
* **Rash**
* Tremor
* Ataxia
* Impaired coordination
* Dizziness
* Diplopia
* Blurred vision
## Footnote
Alopecia may require supplementation with biotin, selenium, and zinc.
48
What should be monitored when a patient is on Lamotrigine?
Rash, fever
## Footnote
Discontinue if there is any sign of hypersensitivity reaction or unspecified rash.
49
What is the recommended action if Lamotrigine is discontinued for ≥ 5 half-lives?
Restart initial dosing titration
## Footnote
This typically means > 6 days for most patients.
50
What effect does Valproic acid have on Lamotrigine concentrations?
Increases Lamotrigine concentrations more than two-fold
## Footnote
A lower dose starter kit (blue box) should be used.
51
What is the difference in dosing starter kits for Lamotrigine?
* Blue: Lower starting dose, use if taking valproic acid
* Orange: Standard starting dose, use if no interacting medications
* Green: Higher starting dose, use if taking an enzyme inducers like carbamazepine, phenytoin, phenobarbital, primidone
## Footnote
The colored starter kits help ensure the correct dose is selected.
52
True or False: Higher maintenance doses of Lamotrigine may be needed when taking oral estrogen-containing contraceptives.
True
## Footnote
This is due to the interaction with Lamotrigine.
53
What effect do Carbamazepine, phenytoin, and related drugs have on Lamotrigine levels?
Decrease Lamotrigine levels by 40%
## Footnote
A higher dose starter kit (green box) should be used.
54
What is the brand name for Levetiracetam?
Keppra, Keppra XR
## Footnote
Levetiracetam is sold under multiple brand names.
55
What are the warnings associated with Levetiracetam?
Psychiatric reactions including psychosis symptoms, somnolence, fatigue
## Footnote
These warnings highlight significant risks that may arise during treatment.
56
What significant drug interactions are associated with Levetiracetam?
No significant DDI
57
What is the IV:PO conversion for Keppra?
1:1
58
What is the brand name for Topiramate?
Topamax
59
What are the warnings associated with Topiramate?
* Hyperchloremic non-anion gap metabolic acidosis,
* oligohidrosis/hyperthermia,
* nephrolithiasis,
* acute myopia and secondary angle-closure glaucoma,
* hyperammonemia,
* visual problems (reversible),
* fetal harm
60
What are common side effects of Topiramate?
**Somnolence**, dizziness, psychomotor slowing, **difficulty with memory/concentration/attention, weight loss, anorexia**, paresthesia
61
What should be monitored during Topiramate therapy?
Electrolytes especially **bicarbonate**, renal function, hydration status, eye exam (**IOP**)
62
What is the effect of Topiramate on oral contraceptives?
Can reduce effectiveness, especially with doses ≥ 200 mg/day
## Footnote
Non-hormonal contraception is recommended.
63
How does Topiramate interact with warfarin?
Can decrease the INR; monitor closely
64
What is another indication for topiramate other than seizures?
migraine ppx
65
What is the primary drug name for Valproate?
Valproic acid
## Footnote
Valproate is also referred to as valproic acid in various formulations.
66
What is a significant boxed warning associated with Valproate?
Hepatic failure, fetal harm (neural tube defects and decreased IQ score), pancreatitis
67
What are common side effects of Valproate?
* **Alopecia**
* **Nausea/vomiting**
* **Weight changes**
* Headache
* Anorexia
* Abdominal pain
* Dizziness
*** Somnolence**
* **Tremor**
* Edema
* Diplopia
* Blurred vision
## Footnote
Alopecia may be managed with biotin, selenium, and zinc supplementation.
68
What monitoring is required for patients on Valproate?
* LFTs
* CBC with differential (especially plt)
* Serum valproate levels
* Serum ammonia
## Footnote
Monitoring is especially important in the first 6 months of therapy.
69
What are indications for valproate other than seizure?
* Bipolar disorder
* Migraine ppx
70
What are the warnings associated with valproate?
* Hyperammonemia
* Dose related thrombocytopenia
71
What is the therapeutic range for valproate?
50-100 mcg/mL (total level)
72
How to treat hyperammonemia associated with valperoate?
treat with carnitine is symptomatic adults only
73
How does valproate effects warfarin levels?
increase
74
Lacosamide brand name?
Vimpat
75
What scheduled class is Lacosamide?
C-V
76
What warning is associated with Lacosamide?
* Prolongs PR interval and increases risk of arrhythmias
* Multiorgan hypersensitivity reaction (DRESS)
## Footnote
An ECG should be obtained prior to use and after titration in at-risk patients.
77
Carbamazepine brand name?
Tegretol, Tegretol XR, Carbatrol, and Epitol.
78
What are the boxed warnings associated with Carbamazepine?
* Serious skin reactions (SJS/TEN)
* Aplastic anemia
* Agranulocytosis
79
What genetic test is required for patients of Asian descent before starting Carbamazepine?
HLA-B*1502 allele testing
80
What are the contraindications for Carbamazepine?
* Myelosuppression
## Footnote
NNRTIs refer to non-nucleoside reverse transcriptase inhibitors.
81
What is the therapeutic range for Carbamazepine?
4-12 mcg/mL
82
What are important warnings associated with carbamazepine?
* Hyponatremia
* fetal harm
83
What is required for monitoring during Carbamazepine therapy?
* CBC with differential
* LFTs
* Rash monitoring
* Eye exam
* Thyroid function tests
* Serum sodium
* Renal function
84
What is a key characteristic of Carbamazepine in terms of drug interactions?
Carbamazepine is an autoinducer and will reduce its own levels.
85
How does carbamazepine effects warfarin levels?
Decreases
86
Oxcarbazepine brand name?
Trileptal
87
What are the warnings associated with Oxcarbazepine?
* Risk for serious skin reactions (SJS/TEN)
* Multiorgan hypersensitivity reactions (DRESS)
* **Hyponatremia**
* Hypothyroidism
* Potential worsening of generalized seizures
88
What genetic test is required for patients of Asian descent before starting Oxcarbazepine?
HLA-B*1502 allele testing
89
What should be monitored during Oxcarbazepine therapy?
* Serum sodium
* Thyroid function
* CBC
## Footnote
Monitoring of serum sodium is especially important during the first 3 months of treatment.
90
What is oxcarbazepine's role in drug interactions?
Oxcarbazepine is a weak CYP3A4 inducer and CYP2C19 inhibitor but is not an autoinducer.
## Footnote
Strong CYP3A4 inducers can decrease oxcarbazepine levels. Non-hormonal contraception is recommended.
91
Phenytoin brand name?
Dilantin, Dilantin infatabs
92
What is the therapeutic range for total phenytoin levels?
10-20 mcg/mL
93
What is the therapeutic range for free phenytoin levels?
1-2 mcg/mL.
94
What are boxed warnings associated with phenytoin use.
* Phenytoin IV administration rate should not exceed 50 mg/min
* Fosphenytoin IV administration rate should not exceed 150 mg PE/min or 2 mg PE/kg/min
--->if given faster can lead to hypotension and cardiac arrythmias
95
What are some warnings associated with phenytoin?
* Extravasation leading to purple glove syndrome
* Multiorgan hypersensitivity reactions (DRESS)
* Fetal harm
* Risk of serious skin reactions (SJS/TEN)
* Blood dyscrasias
* Cardiac arrest
* Hepatic and renal impairment
* Hypothyroidism
## Footnote
Patients with cardiac disease should use caution.
96
What is the IV:PO conversion ratio for phenytoin?
1:1
97
What are some dose-related side effects of phenytoin?
* Nystagmus (an involuntary, rapid, and rhythmic movement of the eyes)
* Ataxia
* Diplopia/blurred vision
## Footnote
These effects are associated with toxicity.
98
What chronic side effects can occur with phenytoin use?
* Gingival hyperplasia
* Hepatotoxicity
99
What monitoring is required for phenytoin therapy?
* Serum phenytoin concentration
* Liver function tests (LFTs)
* CBC with differential
For IV:
* Continuous cardiac monitoring (ECG, BP, HR)
* Respiratory function
## Footnote
Monitoring is crucial for safe phenytoin administration.
100
What should be done with enteral feedings during phenytoin administration?
Hold feedings 1-2 hours before and after administration
## Footnote
This is to ensure adequate absorption of phenytoin.
101
True or False: Fosphenytoin has a lower risk of purple glove syndrome compared to phenytoin.
True
## Footnote
Fosphenytoin is a prodrug of phenytoin.
102
What happens to phenytoin metabolism when enzymes become saturated?
A small increase in the dose can lead to a large increase in drug concentration
## Footnote
Important to monitor levels and make dose changes carefully.
103
What is the corrected phenytoin level formula?
Phenytoin correction = Total phenytoin measured / (0.2 × albumin) + 0.1
## Footnote
Used when albumin is low (< 3.5 g/dL) and CrCl ≥ 10 mL/min.
104
What is the therapeutic range for phenobarbital in adults?
20-40 mcg/mL
105
What are some warnings associated with phenobarbital?
* Caution in substance use disorder
* Respiratory depression
* Fetal harm
106
What are some common side effects of phenobarbital?
* Physiological dependence
* Tolerance
* Residual sedation
107
What is a notable interaction of phenobarbital?
It is a strong inducer of several enzymes, including 3A4 and P-gp.
108
What should be used instead of hormonal contraceptives when taking phenobarbital?
An alternative, non-hormonal contraceptive
109
Name the 'family members' of carbamazepine.
* Oxcarbazepine
* Eslicarbazepine
110
What are the common side effects of carbamazepine, oxcarbazepine, and eslicarbazepine?
* Hyponatremia
* Rash
* Enzyme induction
111
What are the common side effects of gabapentin and pregabalin?
* Weight gain
* Peripheral edema
* Mild euphoria
112
What are the common side effects of phenobarbital and its prodrug, primidone?
* Sedation
* Dependence
* Tolerance
* Overdose risk
* Enzyme induction
113
What are the common side effects of topiramate and zonisamide?
* Weight loss
* Metabolic acidosis
* Nephrolithiasis
* Oligohidrosis/hyperthermia (in children)
114
What are the boxed warnings for benzodiazepines?
Use with opioids can result in profound sedation, respiratory depression and death
115
What is Clobazam (Onfi, Sympazan) used for?
Used for Lennox-Gastaut syndrome or refractory epilepsy
## Footnote
Clobazam is a benzodiazepine.
116
What scheduled class are BZD?
C-IV
117
What are the warnings associated with Ethosuximide (Zarontin)?
* Serious skin reaction
* blood dyscarasias
## Footnote
Ethosuximide is specifically used for absence seizures.
118
What are the boxed warnings for Felbamate (Felbatol)?
Aplastic anemia, hepatic failure
## Footnote
Informed consent needs to be signed prior to dispensing.
119
What is a boxed warning for Fenfluramine (Fintepla)?
Valvular heart disease, pulmonary hypertension
## Footnote
Available only through a restricted distribution program/REMS.
120
What is a warning for Fenfluramine?
Decreased appetite and weight loss
## Footnote
Monitoring is crucial to prevent severe complications.
121
Fill in the blank: _______ is used for absence seizures.
Ethosuximide
## Footnote
Ethosuximide is the primary medication for this type of seizure.
122
What is Gabapentin also known as?
Neurontin
## Footnote
Gabapentin is used primarily for neuropathic pain treatment.
123
What is the classification of Pregabalin?
C-V
124
What are the common side effects of gabapentin?
Dizziness, somnolence, peripheral edema, weight gain, ataxia, diplopia, blurred vision, dry mouth, mild euphoria
## Footnote
These side effects can vary in intensity among different patients.
125
What is the prodrug of phenobarbital?
Primidone
## Footnote
Primidone is converted to phenobarbital and phenylethylmalonamide (PEMA), both of which are active metabolites.
126
What is a contraindication for Zonisamide?
Hypersensitivity to sulfonamides
## Footnote
This contraindication is critical for patient safety.
127
What ia a boxed warning for Vigabatrin?
Permanent vision loss
## Footnote
This can enhance absorption and reduce gastrointestinal side effects.
128
What are the side effects with Zonisamide?
Oligohidrosis/hyperthermia, risk of nephrolithiasis
## Footnote
These side effects are particularly noted in pediatric populations.
129
Which ASMs have therapeutic drug level ranges that are monitored?
Phenytoin, valproic acid, carbamazepine, phenobarbital
## Footnote
These levels help control seizures and minimize toxicity.
130
How can ASMs cause drug interactions?
Through protein binding or enzyme-mediated effects.
131
Name three ASMs that are highly protein-bound.
Phenytoin, valproate, clobazam.
132
What is an example of an enzyme inducer among ASMs?
1. Carbamazepine.
2. Oxcarbazepine
3. Phenytoin
4. Fodphenytoin
5. Phenobarbital
6. Primidone
133
Which ASM is an enzyme inhibitor that increases levels of substrates?
Valproic acid.
134
What must be adjusted when using valproic acid and lamotrigine together?
Dose adjustments to decrease the risk of severe rash.
135
Which ASMs have known teratogenic risks in pregnancy?
Clonazepam, phenobarbital, primidone, phenytoin, fosphenytoin, carbamazepine, valproic acid.
136
Which ASM has the highest teratogenic risk?
Valproic acid.
137
What are the risks associated with valproic acid during pregnancy?
Neural tube defects and impaired cognitive function in the child.
138
Which ASMs are preferred in pregnancy due to lower risk?
Levetiracetam and lamotrigine.
139
What should women of childbearing age on ASMs receive daily?
Folate supplementation.
140
What should women on ASMs avoid to minimize risks?
Unplanned pregnancy.
141
What is a key consideration for women on ASMs regarding contraception?
Many ASMs reduce the efficacy of oral hormonal contraceptives.
142
What nutritional supplementation is required for pregnant patients taking ASMs and why?
Adequate calcium and vitamin D supplementation due to bone loss
143
How do ASM blood levels change during pregnancy?
ASM levels decline during pregnancy and increase in the postpartum period.
144
What risk is associated with low ASM levels during pregnancy?
Seizures, which can be harmful to the baby.
145
What specific risk do topiramate and zonisamide pose in young children?
Reduced sweating (hypohidrosis).
146
What is a potential risk for children taking lamotrigine?
Lamotrigine-induced rash with risk of fatality.
